HomeMy WebLinkAbout0126 OLD TOWN ROAD i ��
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i
Y ?, TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map l� Parcel 6 Application #d6 1_36 NUS
Health Division Date Issued `—
Conservation Division Application Fee J
Planning Dept. Permiffee
G V1 1
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation/ Hyannis
Project Street Address _7�own Abetel
Village
Owner -Xhvcs--rner4 (re wD :7mc-, Address (,,9 1Oee&r7r_ La+
Telephone
Permit Request Re�..o o� �Qcwc u sex 12
, flfl a
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuatio !'0®0 Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family 14 Two Family ❑ Multi-Family (# units)
Age of Existing Structure l IS-0 Historic House: ❑Yes tNo On Old King's Highway: ❑Yes X No
Basement Type: )l Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) 0 Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing Z. new b Half: existing 8 new 0
Number of Bedrooms: I/ existing anew
Total Room Count (not including baths): existing 9 new ® First Floor Room Count
Heat Type and Fuel: '4 Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes NtNo Fireplaces: Existing - New Existing wood/coal stove: ❑Yes 9 No
Detached garage: ❑existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review #
Current Use Proposed Use
_ APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Named r Telephone Number
Address «15 re-ebkLy bewo$Ue. License #
Home Improvement Contractor# /.6,99 73
ail ,,® e@ b� r ,Cif Worker's Compensation # !�S�WZ113`�7.2- PO f U
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
rr
Vt-et- P
SIGNATUR ��',. DATE
i
li
FOR OFFICIAL USE ONLY
APPLICATION#
:4 DATE ISSUED f ' t
:z
MAP/PARCEL NO.
ADDRESS VILLAGE
'a
OWNER
}
DATE OF INSPECTION:
{
. riFOUNDATI.ON.�
FRAME
„t
- :INS.ULATION o �:;•
FIREPLACE
ELECTRICAL:, ROUGH FINAL -
PLUMBING: ROUGH FINAL
F ,r
GAS: ROUGH FINAL
r
FINAL BUILDING ,
DATE CLOSED OUT
` ASSOCIATION"PLAN NO.
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273E CominornmM of Mac&wdtS
Dgwrtmml of Ltd=sbidAcddmtir
Or=vfIn a fiwis
600 Was aronSbvd
BoMon,MA a2 I1
wnfw.�rms�go�t�
Workers' Compensafi=hmn- nce AffAzvit Bml&=JCmAr=ta�chi���n n �ra
AupficantInformatim Please Prid
Name P
City/stateip: �, P 77�c
Am you an employer?Check the agprapr3afie Miagenandconh=torandI
Typ of project(r�ed)-
1.0 I am a employer� 4_ �. El 3Qt tx t:uctioa
employees(fall audlarpwt-ime).* have hired the sub-c
2.❑ I am a sole proprietor orpartner- listed oathe attached sheet 7- EfR,-,, deltag
ship and have:an employees Them snb-cmt wtorz have & ❑Demolition
vcddng for mein any capacity employees and have wmkm 9. ❑But7tFmg addition
INo vrm3mm'camp.insurance comp-iUsMMnMI
�zCLj 5. ❑ We are a eocpmatimaad its 10-0 � or additions
3-❑I am a hamst w=doing all work officers have eanrcised their 11. ]PlunNagsepaiss is a l&dons
mpsel£[No warkrere camp ngbt ofememption per MGL I2.❑Roofrpairs
insurance required.]l c.152,11(4�andwe have na
employees-[No wadome 13-❑Othw
comp_iasuraace requinAj
*Any xppLczmitfttchedabax�l�sta]sofiIleatt�esecfioabetax*shnaria5ffiea
H�nwaest�submitthissf rtindiatia6theyaedoingtHwzkaadthmhtsOuW&c-asdlztanewxMdz7kmdic iH M1 L
�Cmtlacoasthar check thisboa n�attached m ulditinaa!sheet�6 then:meat'/fie and clue tixhether praetihdse entitiesI�
empk7e_ Iftheob-m�hssemWlUmr%lheymustpndskthe-vwarYme=np.poEcymmiber.
lain an antglvyer f7tQtisprtrvidut tuorksra'comJrertsativtx utsuraures for my earpii+}'aes $data is SispaFicp atrrt job sits
ut,farata�fipr1
ksuranm ComPauy
lblicy k or pelf-ins.Lie. 6 V 1� �6 P 3 a-3- 13 i pi=atiaaDat 0�/3 Q 1 1 �J
Job SiteAddresss_ �02� OLc� TOJ.�� l�d. C4#yl5tafrlTp: i�Xd�r NNv S ----
Attacb a copy of the worlwxs'compensmdan policy dedaration page(showing the pwFuy number aid ezph2tinn date).
Farlure to secare coverage as required uncles Section 25A of M L c.152 can lead to the imposition ofcdminal pet Aff of a
fine up to 31,30Q.00 and/or ona-year impriso—f as well.as c ivR pea d ies in the foml of a STOP WORK ORM-and a fine.
of up tv$250.D0 a dap against the violator. Be advised that a copy of thus statement maybe firwarded to the Office of
Irtvestigatioas of Me DIA€or insurance coverage verfficatiorL
I do hereby cer*ender the its and n 'try IhatfLa mformaffan pro vi&ff'ahaw fs irae i m d conaat
km- --J=-J Date: 1 I d
Phone#
O, ciaf mFy. Do oat wr&in biro area,to be eompIated by arhnm aJMX
Chy or Tom P icense#
hofmg AafftorkF(cizdso
L Board cf Hed& 2.l3uing Depa rbnenr 3.C2tyfrm m clerk L Electrical Inspector S.Ploobing Enpector
C C*har
Gbntactl'e:snu: l?imne�
6
NOTICE z '
NOTICE
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TO
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TO
EMPLOYEES �_ EMPLOYEES
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IV
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 — http://www.mass-gov/dia
As required by Massachusetts General Law, Chapter 152,Sections 21,22&30, this will give you notice that
I(we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
ACE GROUP
NAME OF INSURANCE COMPANY
P.O. BOX 1450
MIDDLEBORO MA 02344-1450
ADDRESS OF INSURANCE COMPANY
(6S62U13-4576P30-3-13) 05-30-13 TO 05-30-14
POLICY NUMBER EFFECTIVE DATES
SCHLEGEL & SCHLEGEL INS 34 MAIN ST
WEST YARMOUTH MA 02673
NAME OF INSURANCE AGENT ADDRESS PHONE#
DELLORTO, SILVINO 339 PITCHERS WAY
o�
HYANNIS
MA 02601
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE
=- MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably
connected to the work related injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
)19128 W20PIG02 TO BE POSTED BY EMPLOYER
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Massachusetts- Department of Public Safet%
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 104769
i
PAVEL ZYBAILA
10 AFT ROAD ,
YARMOUTH, MA 02664
Expiration: 8/1/2014
('ununissiuner Tr#: 104769
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston,Massachusetts 02116
Home Improvement Contractor Registration
Registration: 169875
r ` Type: Individual
, .
Expiration: 8/16/2015 Tr# 243186
PAVEL ZYBAILA -
PAVEL ZYBAILA
145 CEDAR ST '
WEST BARNSTABLE, MA 02668
Update Address and return card.Mark reason for change.
Address D.Renewal E] Employment 0 Lost Cai
SCA 1 -o 20M-05/11
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
before the expiration date. If found return to:
OME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation
egistration: `c>169875 Type:
10 Park Plaza-Suite 5170
Expiration ,811612015. Individual Boston,MA 02116
PAVEL ZYBAILA _
PAVEL ZYBAILA
145 CEDAR ST
ou signature
WEST BARNSTABLE, MA 02668 Undersecretary
f
Town of Barnstable
Regulatory Services
MASS.BARNSUBM
Richard V.5ca14 Interim Director
s63g6639. `0�
Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-8624038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
w
hereby authorize PC L e- / /(A to act on my behalf,
in all matters relative to work authorized by this building permit
. !2 G O iol' 7cw�n /7cxxc� �yQh y,�5
(Address of Job)
**Pool fences and alarms are the responsibility of the applicant. Pools
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Signature of Owner Signature of Applicant
gal&w G&-,bcy-Ska'S
Print Name Print Name
z/2-,/3
Date
Town of Barnstable
Regulatory Services
otrtHE Richard V.Scali,Interim Director
Building Division
z
EAMNSTUM Tom Perry,Building Commissioner
i634s 1��' 200 Main Street, Hyannis,MA 02601
pr fD A www.town.barnstable.ma.us
Office: 5.08-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB.LOCATIOI<I:
number street village
"HOMEOWNER':
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-
family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section
109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
procedures and requirements and that he/she will comply with said procedures and requirements.
Signature of Homeowner
Appioval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code
Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt
from the provisions of this section(Section,109.1.1-Licensing of construction Supervisors); provided that if the homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor
(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often
results in serious problems;.particularly when the homeowner hires unlicensed persons. In this case,our Board cannot
proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is
ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as-part of the
permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page
of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in
your community.
•
OAWPFaM\FORMS\building permit forms\E)CPRESS.doc
I F 0 R T E MEMBER REPORT Level 2,Floor.Flush Beam FAILED
CII 4 piece(s) 13/4" x 7 1/4" 1.9E Microllam0 LVL
Overall Length: 12'1"
"k
0 0
- I
tl 11 7" - —
Q
All locations are measured from the outside face of left support(or left cantilever end).All dimensions are horizontal.
Design Results Actual @ Location Allowed Result LDF Load:Combination(Pattern) System:Floor
Member Reaction(Ibs) 3076 @ 1 1/2" 5206(1.75") Passed(59%) 1.0 D+1.0 L(All Spans) Member Type:Flush Beam
Shear(Ibs) 2687 @ 10 1/4" 9643 Passed(28%) 1.00 1.0 D+1.0 L(All Spans) Building Use:Residential
Moment(Ft-Ibs) 9067 @ 6'1/2" 14229 Passed(64%) 1.00 1.0 D+1.0 L(All Spans) Building code:IBC
Live Load Defl.(in) 0.391 @ 6'1/2" 0.296 Failed(L,/363) 1.0 D+1.0 L(All Spans) Design Methodology:ASO
Total Load Defl.(in) 0.563 @ 6'1/2" 0.592 Passed(L/252) 1.0 D+1.0 L(All Spans)
Deflection criteria:LL(L/480)and TL(L/240).
Bracing(Lu):AII compression edges(top and bottom)must be braced at 11'10 1/2"o/c unless detailed otherwise.Proper attachment and positioning of
lateral bracing is required to achieve member stability.
Bearing Length Loads to Supports(Ibs)
Supports e4 Fl
PP Total Available Required Dead Total Accessories
Live
1-Stud wall-SPF 3.00" 1.75" 1.50" 953 2175 3128 1 1/4"Rim Board
2-Stud wall-SPF 3.00" 1.75" 1.50" 953 2175 3128 1 1/4"Rim Board
•Rim Board is assumed to carry all loads applied directly above it,bypassing the member being designed.
Tributary Dead Floor Live
Loads Location Width (0L90) (1.00) ,„ Comments
1-Unifonn(PSF) 0 to 12'1" 12' 12.0 30.0 Residential-Living Areas
K Member Notes
28 AT KITCHEN/DINING
Weyerhaeuser Notes l SUSTAINABLE FORESTRY INITIATIVE
Weyerhaeuser warrants that the sizing of its products will be in accordance with Weyerhaeuser product design criteria and published design values. l
Weyerhaeuser expressly disclaims any other warranties related to the software.Refer to current Weyerhaeuser literature for installation details.
(www.woodbywy.com)Accessories(Rim Board,Blocking Panels and Squash Blocks)are not designed by this software.Use of this software is not intended to
circumvent the need for a design professional as determined by the authority having jurisdiction.The designer of record,builder or framer is responsible to
assure that this calculation is compatible with the overall project.Products manufactured at Weyerhaeuser facilities are third-party certified to sustainable
forestry standards.
The product application,input design loads,dimensions and support information have been provided by SITE W/CLIENT
OF Mggsgcy
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2113
Forte Software operator Job Notes 9/27/2013 10:09:29 AM
Michele Cudito 126 old TOWN RD.,HYN. Forte v4.0,Design Engine:V5.6.1.203
Michele Cudilo,R.E. 2013-1899ARBAUSKAS.4te
(508)771-7601
mcudilo@comcast.net V' Pa e 1 of 1
g
f
Mass. Corporations, external master page Page 1 of 2
William Francis Galvin
Secretary of the Commonwealth of Massachusetts
v
V r
HOME DIRECTIONS CONTACT US Isearch sec state.ma.us Search
Corporations Division
Business Entity Summary
.......
ID Number:001103SSS I Request certificate New search
Summary for: FURTHER INVESTMENT GROUP,INC.
The exact name of the Domestic Profit Corporation: FURTHER INVESTMENT GROUP,INC.
Entity type: Domestic Profit Corporation
Identification Number:001103588
Date of Organization in Massachusetts: 04-01-2013
Last date certain:
Current Fiscal Month/Day: 12/31
The location of the Principal Office:
Address: 69 NEPTUNE LANE
City or town,State, Zip code,Country: S.YARMOUTH, MA 02664 USA
The name and address of the Registered Agent:
Name: MATTHEW GARBAUSKAS
Address: 69 NEPTUNE LANE
City or town,State, Zip code, Country: S.YARMOUTH, MA 02664 USA
The Officers and Directors of the Corporation:
Title Individual Name Address
PRESIDENT MATTHEW GARBAUSKAS 69 NEPTUNE LANE S.YARMOUTH, MA 02664 USA
TREASURER MICHAEL POWERS 69 NEPTUNE LANE S.YARMOUTH, MA 02664 USA
SECRETARY MARY GARBAUSKAS 69 NEPTUNE LANE S.YARMOUTH, MA 02664 USA
DIRECTOR MATTHEW GARBAUSKAS 69 NEPTUNE LANE S.YARMOUTH, MA 02664 USA
DIRECTOR MICHAEL POWERS 69 NEPTUNE LANE S.YARMOUTH, MA 02664 USA
DIRECTOR MARY GARBAUSKAS 69 NEPTUNE LANE S.YARMOUTH, MA 02664 USA
DIRECTOR KAREN POWERS 69 NEPTUNE LANE S.YARMOUTH, MA 02664 USA
DIRECTOR VINCENT ANTON 69 NEPTUNE LANE S.YARMOUTH, MA 02664 USA
Business entity stock is publicly traded: r
The total number of shares and the par value,if any,of each class of stock which this business entity is
authorized to issue:
Class of Stock Par value per share Total Authorized Total issued and outstanding
No.of shares Total par value No.of shares
CNP $ 0.00 275,000 $0.00 275,000
r Consent r Confidential Data r Merger Allowed r Manufacturing
View filings for this business entity:
http://corp.sec.state.ma.us/Corp Web/CorpSearch/CorpSummary.aspx?FEIN=001103588... 11/12/2013
BATH
s
BEDROOM 6-11"x 5'-11"
1 l'-3"x 11'-5"
LIVING
17'-7"x 15'-7"
KITCHEN
fA3
12'-6"x 11'-5"
HALL
10'-9"x 5'-1"
I;
BEDROOM DINING
10'-6"x 11'-2" UP 17'-11"x 11'-2"
i
LIVING AREA c� }p `Ac .
1046 sq ft
t
BATH
T-1"x 5-8„
BEDROOM BEDROOM
9:-2"x 12'-8" 11'-10"x 15 0"
I
HALL r.
T-1"x 4'-11"
CLOSET
CLOSET
9.-2"x 2'-1' -
uP
LIVING AREA
710 sg ft
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05"�^f'
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PROPOSED MODIFICATIONS MICHELE CUDILO, P.E.
Consulting Structural En ineer
Centerville, Massachusetts 02632-1979 508 771-7601
Drawn By: MC Date: 09/24/13 Drawing
126 OLD TOWN RD. Scale: l e-Aq NOTED Rev. 0
HYANNIS, MA S K— 1
File Nome:Gorbouskas Project No.2013-189
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Town of Barnstable *Pert# -
Expires 6 months from issue date
Regulatory Services Fee
NAM Thomas F.Geiler,Director
639. &
Building Division
Tom Perry,CBO, Building Commissioner �/ �'LlG
0� SS `�
200 Main Street,Hyannis,MA 02601 i��
www.town.bamstable.ma.us Office: 508-862-4038 SEP 6-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Map/parcel Number
Not Valid without Red x-PressImprint T WN OF BARNSTABLE
p
Property Address �,�(� co/;%,*w6ot 0"0/ / c �fM4Z,K U� .
Residential Value of Work — A finbbum fee of$35.00 for work under$6000.00
Owner's Name&Address ) c,µf� �µ�cu d r•c
Contractor's Name 'C * Telephone Number 77`'( —IW—DZG8
Home Improvement Contractor License#(if applicable) K>95 1 Email: ?=ZLt 10 l Co`AA-
Construction Supervisor's License#(if applicable) V "c l Ca
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ am the Homeowner
I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy# e6 s zr5 76 P30
Copy of Insurance Compliance Certificate„must accompany each permit.
Permit Request(check box)
Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to N y C 4
Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
Re-side
Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
.***Note: V Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required.
SIGNATURE. 1�
QAWPFMESTORMS\building t forms�EXFRESS.doc
Revised 060513
1!ll
ZVI
s,
The Commornsteah*of Massachusetts
Deparftnr nt of bukstrd Accidents
- Office,t9•f i Ves4latio ns
' 600 Washinrgton Street
Boston,MA 021II
wnjv.Ynassgovldia
Workers' Compensafiaulusnrance Affidavit:BuildersfContractorsMectricians/Plumbers
plicaut Information Please Brent L,egUy
Name sslOFganizalion/individnai): 2 k2 ej
fliddiess: 10 'A _ `►>�or,,• - r HA I 0266g .
City/State/Zip: phone g- 7 7
Are you an employer?Checkthe appropriate b Type v#,project r
� Pr 3 ( equind)=
1.❑ I am a employer with I 4_r I am a general contractor and 1 6- ❑New c�omstrrrction
employees(fall and/or part:time}*t--r" have hired.the sub-contractors
2_❑ I am a sole proprietor or partner- listed on the attached sheet y- ❑Remodeling
ship and have no employees These sob-contractors have g_ ❑Demolition
working for me in any capacity emp"and have workers' 9_ 0 Building addition
[No workers' comp_insurance comp_msurance 1
required] 5- aTe are a corporation and its 10-❑Electrical repairs or additions
3.❑ I am a homeowner doing all wort` officers have exercised their 11-1]Plumbing repairs or additions
myself-[No workers'comp- right of exemption per MGL 12r0 Roof repairs
insurance retluirel]I e-152,§1(4�and we have uo
employees.[No Workers' 13.0 Other
comp-insurance required-1
*Anyappbc,ntthatdhecksboat#1mu talso fill out the section belawshowingtheirwoodcers'compensationpolicyinftnado
Homemwners who submit this afEdm indicating they ace doing all wa t sad then hire outside contractors must submit a new sfidmvh indicating sach..
tContracrors that check this box mast attached an additional sheet shorting the name of the sib-camftaa sand state whether ornot those a adder lave
employees. If the ni&<ontractms hale employees,they mast pwv2de their workers'comp.policy number.
T am an employer that isprmiding workerscompensadon insurance far ncy employees. Below is die policy anal jolt site
in,fotmatiran �D
Insurrance Company Name:
Policy*.or self-ins-Lic. :�S CP —YJ/�l'.JD-3 iration Date:
Job Site Address: I 6 C �19 1-/u V'J Cityf5tatelZip: q `%
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secnrecoyerage as required under Section 25A o€MGL c 152 can lead to the imposition ofcriminal penalties of a
fine up to$1,500.Oa and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to P50-00 a day against the violator- Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insarrance coverage verification-
I do hereby cea&y under thepains andpen 's o peijuty that the infbrmidian provided above r'sand correctDate: 1 . 2013
Phone#:
Offwial use only. Dv not write in this area,to be completed by city or town o,,j dat
Qty or Town: PerudtUcense#
issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityfrowd Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer;or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
i
MGL chapter 152, §25C(6)also states that"every state or IocaI licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance.coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as arefermce number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site'Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for fugue permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Uepa, (mmt Qf Industrial Accidents
Office of kvestigatians
600 Wasshingtou Street
Boston,MA 02111
Tel.#617-727-4900 at 406 or 1-977-MASSAFE
Revised 4-24-07 Fax#617-727-7749
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oFmE T Town of Barnstable
Regulatory Services
yRARN• t .
e MAS&r E g Thomas F.Geiler,Director
16:r6:59.�a Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
`Complete and Sign This Section
' If Using A Builder
Z4�as Owner of the'subject property
hereby authorize � ' to act on ray behalf,
' in all matters relative to work authorized by this building permit
P:'�� ��� P�rgn,�..e•_ `u�e�' �K/oar'�ntTS
(Address of Job)`?
Pool fences and alarms are the responsibility of the applicant. Pools
are not to be filled or utilized'before fence is installed-and all,final
inspections are performed and accepted.
Signature of Owner Signs o t
1
Print Name Print Name
Date ~ F
Q:FORM&OWNERPERMISSIONPOOLS 6/2012
t'
• r
r
FIKE Town of Barnstable
Regulatory Services
y s
vKAB
> S. Thomas F.Geiler,Director
639. Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us t
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: p
JOB LOCATION:
number street village` /
) 1
"HOMEOWNER": 1j
name home phone# work phone#
CURRENT MAILING ADDRESS:-
city/town state zip code t
The current exemption for"homeowners"was extended to include-owner-occupied dwellings of six units or•les4 and to allow
homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be;a one or two-
family dwelling,attached or detached structures accessory to such use and/or farm,structures X person who constructs more than one
home in a two-year period shall not be considered a homeowner.'Such"hbirrieowner"shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shall be responsible for all such work perform6d under the building permit. (Section
109.1.1)
The undersigned"homeowner"assumes responsibility for compl ce with the State Building Code and other applicable codes,
bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Deparfm !minimum inspection
procedures and requirements and that he/she will comply with rocedures and requirements.
P q P y P,_. q
Signature of Homeowner
Approval of Building Official
Note: Three-family'dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code
Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt
from the provisions of this section(Section 109.1.1 Licensing of construction Supervisors);provided that if the homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor
(see Appendix Q,Rules&ReguIations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often
results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our'Board cannot
proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is
ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the
permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page
of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in
your community.
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Revised 053012
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Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 169875
{ Type: Individual
$ m u Expiration: 8/16/2015 Tr# 243186
PAVEL ZYBAILA r<<K
PAVEL ZYBAILA
145 CEDAR ST
WEST BARNSTABLE, MA 02668
Update Address and return card.Mark reason for change.
�e
SCA 1 Co 20M-05n 1 Address Renewal Employment E] Lost Card .
�e tpanurrcaruuealC�i a�C�/l/�aac�ia�eCt�
Office of Consumer Affairs&Business Regulation License or registration valid for individul-use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistration: Sgg75 Type: Office of Consumer Affairs and Business Regulation
Explration:�Z8,I.-1 201!5 Individual 10 Park Plaza-Suite 5170
== - : Boston,MA 02116
„...
'PAVEL ZYBAILA h :- =s- ----------
PAVEL ZYBAILA
145 CEDAR ST
WEST BARNSTABLE,MA 02668 Undersecretary ou signature
Massachusetts - Department of Public S ifeh
Board or Building- Red-ulations and Standards
Construction Supervisor License
License: CS 104769
PAVEL ZYBAILA
10 AFT ROAD
YARMOUTH, MA 02664
Expiration: 8/1/2014
('nmmi<siunrr Tr#: 104769
NOTICE H W NOTICE
TO a TO
EMPLOYEES EMPLOYEES
7 �W
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 — http://www.mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21,22&30,this will give you notice that
I(we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
ACE GROUP
NAME OF INSURANCE COMPANY
P.O. BOX 1450
MIDDLEBORO, MA 02344-1450
ADDRESS OF INSURANCE COMPANY
(GS62U$-4576P30-3-13) 05-30-1 3 TO 05-30-14
POLICY NUMBER EFFECTIVE DATES
m-
SCHLEGEL & SCHLEGEL INS 34 MAIN ST
^� WEST YARMOUTH MA 02673
NAME OF INSURANCE AGENT ADDRESS PHONE#
DELLORTO, SILVINO 339 PITCHERS WAY
0
HYANNIS
MA 02601
m—
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
°J_ provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably
' connected to the work related injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
019128 V'J20P,GU2 TO BE POSTED BY EMPLOYER
f
Mass. Corporations, external master page Page 1 of 2
William Francis Galvin
! Vi
Secretary of the Commonwealth of Massachusetts
J 30
4
m `^0
HOME i DIRECTIONS CONTACT US Search sec state.ma.us 9 Search
Corporations Division
Business Entity Summary
ID Number:001103588 Request certificate 1 New search
Summary for: FURTHER INVESTMENT GROUP,INC.
The exact name of the Domestic Profit Corporation: FURTHER INVESTMENT GROUP,INC.
Entity type: Domestic Profit Corporation
Identification Number: 001103588
Date of Organization in Massachusetts: 04-01-2013
Last date certain:
Current Fiscal Month/Day: 12/31
The location of the Principal Office:
Address: 69 NEPTUNE LANE
City or town,State, Zip code,Country: S.YARMOUTH, MA 02664 USA
The name and address of the Registered Agent:
Name: MATTHEW GARBAUSKAS
Address: 69 NEPTUNE LANE
City or town,State, Zip code,Country: S.YARMOUTH, MA 02664 USA
The Officers and Directors of the Corporation:
Title Individual Name Address
PRESIDENT MATTHEW GARBAUSKAS 69 NEPTUNE LANE S.YARMOUTH, MA 02664 USA
TREASURER MICHAEL POWERS 69 NEPTUNE LANE S.YARMOUTH, MA 02664 USA
SECRETARY MARY GARBAUSKAS 69 NEPTUNE LANE S.YARMOUTH, MA 02664 USA
DIRECTOR MATTHEW GARBAUSKAS 69 NEPTUNE LANE S.YARMOUTH, MA 02664 USA
DIRECTOR MICHAEL POWERS 69 NEPTUNE LANE S.YARMOUTH, MA 02664 USA
DIRECTOR MARY GARBAUSKAS 69 NEPTUNE LANE S.YARMOUTH, MA 02664 USA
DIRECTOR KAREN POWERS 69 NEPTUNE LANE S.YARMOUTH, MA 02664 USA
DIRECTOR VINCENT ANTON 69 NEPTUNE LANE S.YARMOUTH, MA 02664 USA .
Business entity stock is publicly traded: r
The total number of shares and the par value,if any,of each class of stock which this business entity is
authorized to issue:
Total Authorized Total issued and outstanding
Class of Stock Par value per share
No.of shares Total par value No.of shares
CNP $ 0.00 275,000 $ 0.00 275,000
r Consent r Confidential Data r Merger Allowed r Manufacturing
View filings for this business entity:
http://corp.sec.state.ma.us/Corp Web/CorpSearch/CorpSummary.aspx?FEIN=001103 5 88&... 9/13/2013